"*" indicates required fields Basic InformationName* First Last Email* Phone*Phone Type*CellHomeTexting Preferences*Texting OKNo TextingAddress* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about us?*Do you have skills and interests that you would like to share with our residents?*Emergency ContactName* First Last Relationship*Phone*ReferencesReference One – Name* First Last Name of Organization*Phone*Reference Two – Name* First Last Name of Organization*Phone*LocationEHM Senior Solutions has two campus locations in Saline and a variety of volunteer opportunities. The Evangelical Home – Saline is a skilled nursing facility for long-term care located at 440 West Russell Street near Mill Pond Park. Brecon Village, an independent and assisted living residence with a Memory Support Center, is located off N. Ann Arbor-Saline Road at 200 Brecon Drive.At what location would you like to volunteer?*SelectThe Evangelical Home – SalineBrecon VillageAvailabilityPlease indicate when you are available: Monday Morning Afternoon Evening Select AllTuesday Morning Afternoon Evening Select AllWednesday Morning Afternoon Evening Select AllThursday Morning Afternoon Evening Select AllFriday Morning Afternoon Evening Select AllSaturday Morning Afternoon Evening Select AllSunday Morning Afternoon Evening Select AllPlease indicate if you can volunteer Weekly Monthly InterestsPlease indicate how you are interested in volunteering: Select your interests* One on One Visits- Visiting with Residents Best Friends- Building a special relationship with one resident Group Activities- Helping with residents during scheduled activities Volunteering as a Group Outdoor Activities-walking with residents, gardening, crafts Outdoor Facility Care- Decorate windows, fill birdfeeders, work projects Trips/Outings- Accompanying residents and staff on trips Prep Work- Prepping for projects in facility or at home Programing- Creating activities for residents Events or Holidays Other (indicate below) Other InterestsCovid-19 Vaccination StatusVolunteers are not required to be vaccinated. For the safety of our residents, staff, and volunteers, we require volunteers working directly with residents to be tested for Covid-19 at the facility prior to shift.I have had the vaccination for Covid-19 (enter date if yes)I have had the vaccination booster (enter date if yes)Parental Consent (Required If Under Age 18)Consent I authorize my child to participate in the EHM Senior Solutions Volunteer Program.Parent Name First Last SubmitSubmit* Checking this box serves as your digital signature.*CAPTCHA
